Extending growth curves: a trajectory monitoring approach to identification and interventions in struggling medical student learners.

Given gaps in both identifying and providing targeted interventions to struggling learners, the purpose of this study is to both improve rapid identification and to improve individualized academic advising for learners using this visual representation of performance. Across three graduating classes, individual growth curves were calculated for each student on National Board of Medical Examiners customized assessments during the pre-clerkship period using their deviation from the class average at each assessment point. These deviation scores were cumulatively summed over time and were regressed onto the sequence of exams. We analyzed the difference between the regression slopes of those students placed on Academic Probation (AP) versus not, as well as differences in slopes based on the timing of when a struggling learner was placed on AP to explore learner trajectory after identification. Students on AP had an average growth slope of - 6.06 compared to + 0.89 for those not on AP. Findings also suggested that students who were placed on AP early during pre-clerkship showed significant improvement (positive changes in trajectory) compared to students identified later in the curriculum. Our findings suggest that earlier academic probation and intervention with struggling learners may have a positive effect on academic trajectory. Future research can better explore how academic trajectory monitoring and performance review can be regularly used in advising sessions with students.

Performance of five FDA-approved rapid antigen tests in the detection of 2009 H1N1 influenza A virus.

Rapid antigen tests are commonly used by clinicians for rapid, simple, point-of-care testing. Five rapid antigen tests were shown to have low sensitivity (40.3-58.8%) when compared to real-time RT-PCR using nasal wash specimens from patients with influenza-like-illness (N = 167) that were collected previously and confirmed as 2009 pandemic influenza A (H1N1)-positive by PCR. Rapid antigen test sensitivity correlated with virus levels in nasal secretions when comparisons were made to cycle threshold (C(T)) values obtained from real-time RT-PCR. When C(T) values are <25 (equating to viral concentrations of >10(4) TCID(50)/ml) sensitivity for all five rapid antigen kits was high (range: 83-94% positive); however, when C(T) values are >30 (10(2) TCID(50)/ml), sensitivities of only 16-18% were observed for four of five rapid antigen kits. The Directigen EZ Flu A + B test detected more positive samples (35%) at lower viral concentrations with C(T) values >30 when compared with other commercial kits (P = 0.05). Rapid antigen test results must be interpreted with caution, and negative specimens may need confirmation by sensitive molecular assays.

ACGME Milestones in the Real World: A Qualitative Study Exploring Response Process Evidence.

Background: Since the Accreditation Council for Graduate Medical Education (ACGME) introduced the Milestones in 2013, the body of validity evidence supporting their use has grown, but there is a gap with regard to response process. Objective: The purpose of this study is to qualitatively explore validity evidence pertaining to the response process of individual Clinical Competency Committee (CCC) members when assigning Milestone ratings to a resident. Methods: Using a constructivist paradigm, we conducted a thematic analysis of semi-structured interviews with 8 Transitional Year (TY) CCC members from 4 programs immediately following a CCC meeting between November and December 2020. Participants were queried about their response process in their application of Milestone assessment. Analysis was iterative, including coding, constant comparison, and theming. Results: Participant interviews identified an absence of formal training and a perception that Milestones are a tool for resident assessment without recognizing their role in program evaluation. In describing their thought process, participants reported comparing averaged assessment data to peers and time in training to generate Milestone ratings. Meaningful narrative comments, when available, differentiated resident performance from peers. When assessment data were absent, participants assumed an average performance. Conclusions: Our study found that the response process used by TY CCC members was not always consistent with the dual purpose of the Milestones to improve educational outcomes at the levels of residents and the program.

Curricular Change and Resiliency in the Era of Coronavirus (COVID-19): The Uniformed Services University of the Health Sciences (USU) Experience.

INTRODUCTION: The Coronavirus (COVID-19) pandemic has presented a myriad of organizational and institutional challenges. The Uniformed Services University of the Health Sciences, like many other front line hospitals and clinics, encountered a myriad of challenges in fostering and sustaining the education of students enrolled at the nation's only military medical school. Critical to the function of any academic medical institution, but particularly one devoted to the training of future physicians for the Military Health System, was the ability to rapidly adapt, modify, and create new means of keeping medical students engaged in their core curricula and progressing toward full and timely attainment of established educational goals and objectives. METHODS: This article highlights some of the particular challenges faced by faculty and students during the first 6 months of the COVID-19 pandemic and describes how they were managed and/or mitigated. RESULTS: Six key "lessons learned" were identified and summarized in this manuscript. These lessons may be applicable to other academic institutions both within and outside of the Military Health System. CONCLUSIONS: Recognizing and embracing these key tenets of academic change management can accelerate the generation of a cohesive, organizational response to the next pandemic or public health crisis.

Successful treatment of vancomycin-resistant enterococcal ventriculitis in a pediatric patient with linezolid.

Although vancomycin-resistant Enterococcus infection of the central nervous system is not common, this organism is becoming an increasing problem in nosocomial infections. We report a 17-month-old male infant with an externalized ventricular peritoneal shunt secondary to infection who subsequently developed a vancomycin-resistant Enterococcus faecium ventriculitis. This infection was successfully treated with a 28-day course of linezolid while monitoring linezolid drug levels in both the cerebral spinal fluid and serum. This case supports the use of linezolid in treating such resistant infections. However, our drug level results suggest that further investigation is needed to determine the optimal dosing of linezolid in treatment of central nervous system infection in pediatric patients.

Postoperative septic arthritis with Eikenella corrodens and Streptococcus mitis following arthroscopic anterior cruciate ligament reconstruction in an adolescent: A case report and review of the literature.

We present a case of postoperative septic arthritis with Eikenella corrodens and Streptococcus mitis following an arthroscopic anterior cruciate ligament reconstruction in an adolescent male with no pertinent medical history. The patient presented to the emergency department nine days after the operation with fever, an elevated white blood cell count, knee pain, and effusion. Arthrocentesis of the knee yielded purulent fluid that tested positive for S. mitis. Repeat intraoperative cultures revealed E. corrodens. In addition to antibiotics, the patient's treatment course included arthroscopic irrigation and debridement in the operating room as well as removal of graft material and fixation devices. To our knowledge, this is the first case of a polymicrobial infection of E. corrodens and S. mitis causing septic arthritis in a teenager following arthroscopic anterior cruciate ligament reconstruction.

Changing Susceptibility of Staphylococcus aureus in a US Pediatric Population.

BACKGROUND: Staphylococcus aureus is a major cause of infection in both adult and pediatric populations. After several decades of increasing prevalence, the proportion of S aureus infections due to methicillin-resistant S aureus has been reported to be in decline in adults. Data for similar changes in pediatric populations are limited. METHODS: Evaluation of S aureus susceptibility data for pediatric patients receiving care in the US Military Health System was performed. Microbiology and demographic data were collected for years 2005 through 2014. Trends in antibiotic susceptibility results were evaluated. Clinical and demographic characteristics were explored to assess for association with antibiotic susceptibilities. RESULTS: In this study, 41 745 S aureus isolates from 39 207 pediatric patients were included. An overall increase in susceptibility of isolates to oxacillin was noted over this 10-year period; with over 60% of isolates oxacillin-susceptible in 2014. S aureus susceptibility to clindamycin declined over the study period; notably methicillin-susceptible S aureus susceptibility to clindamycin declined from 90% to 83% (P < .0001). Differences in oxacillin susceptibility between US regions decreased over time. CONCLUSIONS: Similar to recent trends seen in adults, the proportion of pediatric S aureus infections secondary to methicillin-resistant S aureus appear to be decreasing, as is variability in US geographical resistance rates. Increasing clindamycin resistance among methicillin-susceptible S aureus should raise caution in the use of empirical clindamycin in presumed S aureus infection. Clinicians should be aware of regional susceptibility patterns when choosing empirical regimens.

Antimicrobial resistance acquisition after international travel in U.S. travelers.

BACKGROUND: Prior studies have shown an increase in multidrug-resistant (MDR) E. coli colonization from two percent in U.S.-based to 11 % in deployed, healthy military personnel. It is unclear if colonization with MDR organisms occurs through deployment exposures or risks related to routine overseas travel. This study prospectively evaluates rates and risk factors associated with MDR gram-negative bacterial and methicillin-resistant S. aureus (MRSA) colonization after international travel. METHODS: Participants traveled internationally for five or more days. Pre- and post-travel, colonizing bacteria from oropharyngeal, nares, groin, and peri-rectal (PR) areas were collected using BD CultureSwab™ MaxV(+). Identification and susceptibilities were done utilizing the BD Phoenix™ Automated Microbiology System. Non-MDR pre- and post-travel MDR bacteria within a subject were compared by pulsed-field gel electrophoresis (PFGE). A questionnaire solicited demographics and potential risk factors for MDR acquisition. RESULTS: Of 58 participants, 41 % were male and median age was 64 years. Pre- and post-travel swabs were obtained a median of ten and seven days before and after travel, respectively. Itineraries included 18 participants traveling to the Caribbean and Central America, 17 to Asia, 16 to Africa, 5 to Europe, 4 to South and North America. Seventeen of 22 travelers used atovaquone/proguanil for malaria prophylaxis. The only MDR organism isolated was extended-spectrum ß-lactamase (ESBL)-producing E. coli in five (9 %) participants post-travel (all PR and unrelated by PFGE). There were no statistically significant associations between exposure risks and new ESBL-producing E.coli colonization. Of 36 participants colonized with E. coli pre- and post-travel, new resistance was detected: TMP/SMX in 42 % of isolates (p < 0.01), tetracycline in 44 % (p < 0.01), and ampicillin-sulbactam in 33 % (p = 0.09). No participants were colonized with MRSA pre- or post-travel. CONCLUSION: Consistent with prior studies, new antimicrobial resistance was noted in colonizing E. coli after international travel. Nine percent of participants acquired new strains of ESBL-producing E.coli without identified risks.